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entitled 'Influenza Pandemic: DOD Has Taken Important Actions to
Prepare, but Accountability, Funding, and Communications Needed to be
Clearer and Focused Departmentwide' which was released on October 23,
2006.
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Report to the Committee on Government Reform, House of Representatives:
United States Government Accountability Office:
GAO:
September 2006:
Influenza Pandemic:
DOD Has Taken Important Actions to Prepare, but Accountability,
Funding, and Communications Need to be Clearer and Focused
Departmentwide:
Influenza Pandemic:
GAO-06-1042:
GAO Highlights:
Highlights of GAO-06-1042, a report to the Chairman and Ranking
Minority Member, Committee on Government Reform, House of
Representatives
Why GAO Did This Study:
An influenza pandemic would be of global and national significance and
could affect large numbers of Department of Defense (DOD) personnel,
seriously challenging DOD’s readiness.
GAO was asked to examine DOD’s pandemic influenza preparedness efforts.
This report focuses on DOD’s planning for its workforce, specifically
(1) actions DOD has taken to prepare and (2) challenges DOD faces going
forward. GAO analyzed guidance, contracts, and plans, and met with DOD
officials.
What GAO Found:
DOD had taken a number of actions since September 2004 to prepare for
an influenza pandemic, and its planning efforts continue to evolve. The
Implementation Plan for the National Strategy for Pandemic Influenza,
released in May 2006, tasked each federal department to develop its own
implementation plan that details how it will carry out its
responsibilities as outlined in the national plan and how it will
prepare its workforce. DOD established working groups for its pandemic
influenza planning efforts, including the Pandemic Influenza Task
Force, which included representatives from across the department,
including the Offices of the Assistant Secretary of Defense (ASD) for
Homeland Defense, ASD for Health Affairs, ASD for Special Operations
and Low Intensity Conflict, and the Joint Chiefs of Staff. In addition,
the Office of the ASD for Health Affairs developed guidance that
provided tasks for the Office of the Secretary of Defense, military
departments, installation commanders, and others to complete to prepare
for a pandemic. Further, several entities within DOD drafted plans and
guidance, and DOD had taken other important steps, such as establishing
Web sites, stockpiling vaccines and antivirals, and initiating projects
to assist other nations with their preparedness efforts.
Going forward, DOD faces four management challenges that it needs to
address as it shifts its focus to the department as a whole. First, at
the time of GAO’s review, neither the Secretary of Defense nor the
Deputy Secretary of Defense had yet issued guidance defining lead and
supporting roles and responsibilities with clear lines of authority,
oversight mechanisms, and goals and performance measures for DOD’s
influenza pandemic planning efforts. The lack of these accountability
mechanisms over time may hamper the leadership’s ability to ensure that
planning efforts across the department are progressing as intended.
Second, DOD had not yet requested funding for its pandemic influenza
preparedness efforts linked to departmentwide goals. Therefore, it is
unclear whether DOD can address the tasks assigned to it in the
national implementation plan and pursue its own preparedness efforts
for its workforce departmentwide within current resources. Third, DOD
had not yet fully defined or communicated departmentwide which types of
personnel—military and civilian personnel, contractors, beneficiaries,
and dependents—it plans to include in its distribution of vaccines and
antivirals. Fourth, DOD had not yet fully developed its communications
strategy or communicated information to its personnel departmentwide on
what actions to take in the event of an influenza pandemic. Also, DOD
had not yet developed a plan to communicate information on the safety
and efficacy of vaccines and antivirals, if DOD decides to dispense
them. While DOD established Web sites with some information on pandemic
influenza, GAO identified some unevenness across the department in
terms of the information personnel received. A comprehensive and
effective communications strategy could ensure that DOD’s personnel
departmentwide are aware of actions they should take in the event of an
influenza pandemic.
What GAO Recommends:
GAO recommends that DOD
(1) define and communicate roles and responsibilities, oversight
mechanisms, and goals and performance measures for DOD’s efforts, (2)
establish a framework to request funding, tied to its goals, (3) define
and communicate departmentwide which types of personnel DOD plans to
include in its vaccine and antiviral distribution, and (4) implement a
comprehensive and effective departmentwide communications strategy. DOD
generally concurred with four recommendations, and did not address one
in its written comments. Based on DOD’s comments and additional
information provided showing DOD designated a lead authority for its
efforts, GAO combined two recommendations. GAO clarified another
recommendation to focus on requesting funding tied to the department’s
goals.
[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-06-1042].
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Davi M. D'Agostino at
(202) 512-5431 or DAgostinoD@gao.gov.
[End of Section]
Contents:
Letter:
Results in Brief:
Background:
DOD Had Taken Actions to Prepare for an Influenza Pandemic:
Going Forward, DOD Faces Four Key Management Challenges in Its Pandemic
Influenza Planning and Preparedness Efforts for Its Workforce
Departmentwide:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Scope and Methodology:
Appendix II: Summary of DOD's Guidance for Pandemic Influenza and
Related Force Health Protection Policies:
Appendix III: Comments from the Department of Defense:
Appendix IV: GAO Contact and Staff Acknowledgments:
Related GAO Products:
Table:
Table 1: DOD's Current Priorities for Vaccine and Antiviral
Distribution:
Figures:
Figure 1: Issues to Be Addressed in DOD's Pandemic Influenza
Implementation Plan:
Figure 2: Comparison of WHO Pandemic Phases and U.S. Government Stages:
Figure 3: Timeline of Actions DOD Has Taken to Prepare for an Influenza
Pandemic Compared to Key Homeland Security Council Plans:
Abbreviations:
ASD: Assistant Secretary of Defense:
DOD: Department of Defense:
HHS: Department of Health and Human Services:
WHO: World Health Organization:
United States Government Accountability Office:
Washington, DC 20548:
September 21, 2006:
The Honorable Tom Davis:
Chairman:
The Honorable Henry A. Waxman:
Ranking Minority Member:
Committee on Government Reform:
House of Representatives:
An influenza pandemic--a novel strain of influenza virus to which
humans have little or no immunity that has the ability to infect and be
passed efficiently between humans worldwide--would be of global and
national significance. A large number of Department of Defense (DOD)
personnel potentially could be affected by an influenza pandemic, which
could adversely affect the military's readiness, jeopardize ongoing
military operations overseas, and threaten the day-to-day functioning
of the department and maintenance of its critical infrastructure. For
example, approximately one-half of all of the deaths of U.S.
servicemembers from World War I, at least 43,000 deaths, were due to
influenza or influenza-related complications, and another 1 million
servicemembers were hospitalized, limiting the military's resources to
continue ongoing missions. An influenza pandemic outbreak not only
would be a medical problem, but also a human capital and national
security problem. The federal government anticipates an influenza
pandemic would occur in multiple waves over a period of time, rather
than as a discrete event. During the peak weeks of an outbreak of a
severe influenza pandemic, an estimated 40 percent of the U.S.
workforce may not be at work due to illness, the need to care for
family members, or fear of infection.
Planning for an influenza pandemic is a difficult and daunting task,
particularly because so much is currently unknown about a potential
pandemic. While some scientists and public health experts believe that
the next influenza pandemic could be spawned by the H5N1 strain of
avian influenza (also known as "bird flu") that is currently
circulating in parts of Asia, the Middle East, Europe, and Africa, it
is unknown when an influenza pandemic will occur, where it will begin,
or whether a variant of the H5N1 strain or some other strain would be
the cause. Moreover, the severity of an influenza pandemic, as well as
the groups of people most at risk for infection, cannot be accurately
predicted. Additionally, responding to an influenza pandemic would be
more challenging than dealing with annual influenza in several ways.
Each year, annual influenza causes approximately 226,000
hospitalizations and 36,000 deaths in the United States. According to
the World Health Organization (WHO), an influenza pandemic would spread
throughout the world very quickly, usually in less than a year, and
could sicken more than a quarter of the global population, including
young, healthy individuals who are not normally as affected by the
annual influenza. However, despite all of these uncertainties, sound
planning and preparedness could lessen the impact of any influenza
pandemic.
To address the potential threat of an influenza pandemic, the Homeland
Security Council issued its National Strategy for Pandemic Influenza in
November 2005.[Footnote 1] The Implementation Plan for the National
Strategy for Pandemic Influenza,[Footnote 2] which was released in May
2006, proposes actions for federal departments--including DOD--in
support of the national strategy and describes expectations for
nonfederal entities, including state, local, and tribal governments;
the private sector; international partners; and individuals. The
national implementation plan tasked each federal agency to develop an
implementation plan that addresses two issues, as shown in figure 1.
First, each federal department was to detail how it would carry out the
department's responsibilities in the national implementation plan. For
example, of the more than 300 actions in the national implementation
plan, DOD was responsible for 114 actions--31 actions as a lead agency
and 83 actions as a supporting agency. Second, each federal department
was to include the department's approach to employee safety, continuity
of operations, and communications with stakeholders in its
implementation plan.
Figure 1: Issues to Be Addressed in DOD's Pandemic Influenza
Implementation Plan:
[See PDF for image]
Source: GAO analysis.
[End of figure]
WHO defines the emergence of an influenza pandemic in six phases (see
fig. 2). Based on this definition, the world currently is in phase 3,
in which there are human infections from a new influenza subtype, but
no or very limited human-to-human transmission of the disease. In
addition, the Homeland Security Council developed "stages," also shown
in figure 2, to provide a framework for a federal government response
to an influenza pandemic, which characterize the outbreak in terms of
the threat that the pandemic virus poses to the U.S. population.
Currently there are new domestic animal outbreaks in an at-risk
country, which is stage 0.
Figure 2: Comparison of WHO Pandemic Phases and U.S. Government Stages:
[See PDF for image]
Source: Homeland Security Council.
[End of figure]
You asked that we examine DOD's planning and preparedness efforts for
an influenza pandemic. Because DOD's implementation plan was still
being drafted at the time of our review, we focused our work on DOD's
pandemic influenza planning and preparedness efforts to date for its
own workforce. DOD is a large, complex organization of departments,
agencies, and other components with a workforce spread around the
world, which, as of April 30, 2006, included nearly 1.4 million active
duty military personnel and nearly 675,000 civilian personnel. This
total does not include the numerous reserve and mobilized National
Guard personnel,[Footnote 3] contractors, dependents, and beneficiaries
for which DOD also is responsible.
We are reporting to you at this time to highlight some of our
observations to date on DOD's approach to planning and preparing to
protect its workforce so DOD can consider and address them as the
department continues its ongoing planning efforts. This report is
largely focused on DOD's plans to protect its own workforce and
addresses (1) actions DOD has taken to date to prepare for an influenza
pandemic and (2) management challenges DOD faces going forward as the
department continues its planning efforts. We expect to issue another
report at a later date on DOD's plans and preparedness for an influenza
pandemic, which will include our evaluation of DOD's final
implementation plan, the combatant command plans, and selected
installation plans.
To address these objectives, we reviewed a draft of the department's
implementation plan for pandemic influenza dated March 2006;[Footnote
4] guidance and planning orders for pandemic influenza issued by the
Assistant Secretary of Defense (ASD) for Health Affairs, the Joint
Chiefs of Staff, Army Medical Command, and Army Installation Management
Agency; and the department's existing directives for force health
protection. Also, we reviewed the Implementation Plan for the National
Strategy for Pandemic Influenza, the Department of Health and Human
Services' (HHS) contract with a vaccine manufacturer, and DOD's
contracts with two antiviral manufacturers. Additionally, we met in the
Washington, D.C., area with cognizant DOD officials from the Office of
the Secretary of Defense, including officials from the Offices of the
ASD for Homeland Defense, ASD for Health Affairs, and ASD for Special
Operations and Low Intensity Conflict; the Joint Chiefs of Staff; and
each of the military services. Some officials from these offices were
involved in the development of the National Strategy for Pandemic
Influenza and its implementation plan. We conducted our review from
December 2005 through August 2006 in accordance with generally accepted
government auditing standards. Further details on our scope and
methodology are in appendix I.
Results in Brief:
DOD has taken a number of important actions to prepare for an influenza
pandemic since September 2004, well before the federal government
released the National Strategy for Pandemic Influenza in November 2005
and its implementation plan in May 2006, and these efforts continue to
evolve. Going forward, DOD faces several management challenges as it
continues its ongoing planning efforts. Certain offices within DOD
established working groups, such as the Pandemic Influenza Task Force,
which coordinated and implemented DOD's pandemic influenza policies and
plans. Also, in September 2004 and January 2006, the ASD for Health
Affairs issued guidance to the military departments, which, among other
things, provided tasks for several DOD organizations to complete for
each of WHO's phases of an influenza pandemic. The guidance also
established generic priorities for the distribution of vaccines and
antivirals. For example, deployed forces engaged in or supporting armed
conflict and those personnel necessary to provide essential health care
for the force are in the top tier of DOD's prioritization system.
Further, at the time of our review, two of the three military
departments--the Departments of the Navy and the Air Force--planned to
issue servicewide instructions related to pandemic influenza
preparedness. The Department of the Army did not plan to issue a
similar instruction, but two organizations within the Army issued
guidance to installations on developing pandemic influenza plans. DOD
also was undertaking influenza pandemic planning efforts at several
different levels. Specifically, DOD completed its implementation plan
for an influenza pandemic, as required by the Implementation Plan for
the National Strategy for Pandemic Influenza. The department started
drafting its implementation plan in November 2005. The Joint Chiefs of
Staff tasked the geographic combatant commands to develop plans, which
were to address force health protection and defense support to civil
authorities, among other things. According to officials from the Joint
Staff, these plans were near completion at the time of our review.
Installations were tasked by the ASD for Health Affairs to develop
pandemic influenza plans or revise existing plans to address pandemic
influenza. Also, DOD established Web sites, including the Pandemic
Influenza Watchboard, that provided information for servicemembers and
their families about avian and pandemic influenza. Moreover, DOD
procured more than 2 million treatment courses of one antiviral, which
were prepositioned in the continental United States, Europe, and the
Far Eas[Footnote 5]t. Additionally, DOD procured over 2 million doses
of an existing H5N1 vaccine, based on the strain that circulated in
Vietnam in 2004, and planned to purchase in fiscal year 2007 additional
doses of the Vietnam strain and a strain that circulated in Indonesia
in 20[Footnote 6]05. Internationally, the department initiated projects
to help build host nation capacity to prepare for, mitigate, and
respond to a potential influenza pandemic.
At the time of our review, DOD's planning efforts to protect its
personnel focused primarily on the military departments, geographic
combatant commands, and installations. However, as DOD's focus shifts
to the workforce departmentwide, including the civilian workforce and
personnel in defense agencies, we identified four key management
challenges that DOD faces going forward as it continues its planning
and preparedness efforts for pandemic influenza. In our prior work, we
identified six desirable characteristics of national strategies,
including defining organizational roles, responsibilities, and
coordination; identifying goals, subordinate objectives, activities,
and performance measures; and addressing resources, investments, and
risk management.[Footnote 7] However, to date, DOD's pandemic influenza
planning may not be as effective as it could be because the department
had not yet (1) clearly and fully defined and communicated
departmentwide roles and responsibilities with clear lines of
authority, oversight mechanisms, and goals and performance measures;
(2) requested funding that is tied to the departmentwide goals of
pandemic influenza to complete the tasks in the national implementation
plan and to protect DOD's own workforce; (3) clearly defined the types
of personnel--military personnel, civilian personnel, contractors,
dependents, and beneficiaries--to be included in DOD's vaccine and
antiviral distribution; and (4) implemented a departmentwide
communications strategy. Specifically, at the time of our review, the
following conditions existed.
* First, neither the Secretary of Defense nor the Deputy Secretary of
Defense had yet issued guidance clearly and fully defining and
communicating lead and supporting roles and responsibilities for DOD's
pandemic influenza planning with clear lines of authority; oversight
mechanisms, including reporting requirements; and departmentwide goals--
such as a description of a desired end-state--and performance measures.
Some officials told us that the lines of authority for DOD's pandemic
influenza planning efforts were unclear. For example, officials told us
that some installation personnel were confused about whether or not
they were supposed to be developing plans, since it was unusual for the
ASD for Health Affairs to task installations directly with developing
plans, and we observed differences in the military departments'
approaches to installation planning. Further, DOD instituted reporting
requirements for the organizations responsible for implementing the 31
tasks from the national implementation plan; however, there were not
similar oversight mechanisms in place for tasks that were not part of
the national implementation plan. For example, the January 2006 Health
Affairs guidance tasked installations with developing pandemic
influenza plans or modifying existing plans to address pandemic
influenza and DOD's implementation plan tasked all DOD organizations
with developing or modifying continuity of operations plans to address
pandemic influenza; however, there were no reporting requirements for
these tasks. Finally, Navy officials said that they started developing
plans for pandemic influenza, but it was difficult because the Office
of the Secretary of Defense had not provided specific goals for what
would be expected of the services in the event of an influenza
pandemic. Over time, a lack of clear lines of authority, oversight
mechanisms, and goals and performance measures could hamper the
leadership's abilities to ensure that planning efforts across the
department are progressing as intended as DOD continues its pandemic
influenza planning and preparedness efforts. Additionally, without
clear departmentwide goals, it may be difficult for all DOD components
to develop effective plans and guidance.
* Second, at the time of our review, DOD had started identifying
funding requirements, but had not yet identified an appropriate funding
mechanism or requested funding, tied to its departmentwide goals, for
its pandemic influenza planning efforts. An official from the Office of
the ASD for Homeland Defense said the department had options for
requesting the required funding, including incorporating the request in
future budget submissions or submitting a supplemental request to the
Congress. Because DOD had not yet requested funding, it is unclear
whether DOD can address the tasks assigned to it in the national
implementation plan and pursue its own preparedness efforts for its
workforce departmentwide within current resources.
* Third, at the time of our review, DOD had not yet clearly defined or
communicated departmentwide which types of personnel--military
personnel, civilian personnel, contractors, beneficiaries, and
dependents--the department planned to include in its distribution of
vaccines and antivirals in the event of an influenza pandemic. The ASD
for Health Affairs issued generic priorities for the department's
vaccine and antiviral distribution and noted that these priorities
would be clarified when more was known about a pandemic strain. An
official in the Office of the ASD for Homeland Defense said
distinctions in the types of personnel who would be included in the
distribution of DOD-purchased vaccines and antivirals would be based on
whether the individual was identified as critical to the execution of
an essential function, as determined by components as they develop or
modify their continuity of operations plans to address pandemic
influenza. A factor affecting DOD's ability to clarify priorities for
distributing vaccines among its personnel is that the department's
priority for receiving additional vaccines, including the vaccine for
the pandemic strain, from HHS was not yet defined at the time of our
review. As a result the department cannot realistically determine how
well it will be able to meet its priorities for vaccinating personnel,
and without knowing a rough estimate of how many vaccines will be
available, DOD cannot accurately determine the funding required to
purchase vaccines or, if needed, additional antivirals.
* Fourth, DOD had communicated information to many of its personnel
about what actions they should take in the event of an influenza
pandemic; however, these communication efforts were inconsistent
departmentwide. Also, although DOD had not yet decided when, whether,
or under what conditions it would dispense the vaccines and antivirals
it purchased to date, DOD did not yet have a plan to communicate with
personnel information on the safety and efficacy of vaccines and
antivirals it purchased to date.[Footnote 8] However, DOD had posted on
one of its Web sites the package inserts for the two antivirals that it
purchased. While DOD established Web sites with some information on
pandemic influenza, we identified unevenness across the department in
terms of offices that regularly received actively distributed messages
and other information. Without a comprehensive and effective
communications strategy departmentwide, DOD personnel's awareness of
actions that should be taken in the event of an influenza pandemic
could become uneven and lead to confusion and increased numbers of
affected personnel.
As DOD continues its planning efforts going forward, and to enhance
DOD's ongoing planning efforts, we are making recommendations to the
Secretary of Defense. Specifically, we are recommending that the
Secretary of Defense (1) instruct the ASD for Homeland Defense, as the
individual accountable for DOD's pandemic influenza planning and
preparedness efforts, to clearly and fully define and communicate
departmentwide the roles and responsibilities of the organizations that
will be involved in DOD's efforts with clear lines of authority; the
oversight mechanisms, including reporting requirements, for all aspects
of DOD's pandemic influenza planning efforts, to include those tasks
that are not part of the national implementation plan; and the goals
and performance measures of DOD's preparedness efforts; (2) instruct
the ASD for Homeland Defense to work with the Under Secretary of
Defense (Comptroller) to establish a framework for requesting funding
for the department's preparedness efforts that includes the appropriate
funding mechanism and controls to ensure needed funding for DOD's
pandemic influenza preparedness efforts is tied to the department's
goals; (3) instruct the ASD for Health Affairs to clarify DOD's
guidance to explicitly define and communicate departmentwide whether
and how all types of personnel--military and civilian personnel,
contractors, dependents, and beneficiaries--would be included in DOD's
distribution of vaccines and antivirals, and (4) instruct the ASD for
Public Affairs to implement a comprehensive and effective
communications strategy for personnel departmentwide.
In written comments on a draft of this report, DOD generally concurred
with four of our recommendations, and did not address one
recommendation. DOD's comments and our evaluation of them are in the
agency comments section of this report. Based on DOD's comments and
additional documentation that DOD provided, we combined two of our
recommendations and clarified another. Specifically, DOD provided
additional documentation showing that the Deputy Secretary of Defense
designated the ASD for Homeland Defense to lead the department's
pandemic influenza efforts. Therefore, we deleted part of the original
recommendation that the Secretary of Defense or Deputy Secretary of
Defense designate an individual to be accountable for DOD's efforts.
Additionally, DOD commented that it had started to determine funding
requirements for its pandemic influenza efforts. We recognized this in
our draft report and, subsequently, we clarified the recommendation to
focus on requesting funding that is tied to the department's goals.
Background:
Occasionally, worldwide influenza epidemics--called pandemics--occur
that can have successive "waves" of disease that can last for up to 3
years. Three influenza pandemics occurred in the twentieth century.
Notable among these was the influenza pandemic of 1918, called the
"Spanish flu," which killed at least 20 million people worldwide,
including 500,000 in the United States.[Footnote 9] The past pandemics
have spread worldwide within months and a future pandemic is expected
to spread even more quickly given modern travel patterns. The major
implication of such a rapid spread is that many, if not most, countries
will have minimal time to implement preparations and responses once a
pandemic virus begins to spread.
The current pandemic influenza threat stems from an unprecedented
outbreak of H5N1 avian influenza that began in Hong Kong in 1997 and
has spread in bird populations across parts of Asia, the Middle East,
Europe, and Africa, with limited infections in humans. The Food and
Agriculture Organization of the United Nations reported in August 2006
that more than 220 million poultry were culled as a preventive measure
or died from the H5N1 strain. From January 2003 through August 2006,
WHO reported more than 240 confirmed human cases and more than 140
confirmed human deaths from the H5N1 virus. Scientists and public
health officials agree that the rapid spread of the H5N1 virus in birds
and the occurrence of limited infections in humans have increased the
risk that this disease may mutate into a form that is easily
transmissible among humans, resulting in an influenza pandemic. Some
experts at WHO and elsewhere believe that the world is now closer to
another influenza pandemic than at any time since the last influenza
pandemic in 1968. According to Central Intelligence Agency officials,
the likelihood of an influenza pandemic occurring within the next 5
years is greater than any other time in the past 40 years. Furthermore,
the agency officials reported that H5N1 is the most likely of all
influenza viruses to cause a pandemic. Three conditions must be met
before an influenza pandemic begins: (1) a new influenza virus subtype
that has not previously circulated in humans must emerge, (2) the virus
must be capable of causing disease in humans, and (3) the virus must be
capable of being passed easily among humans. The H5N1 virus meets the
first two of these three conditions.
We previously reported vaccination is considered the first line of
defense for preventing or reducing influenza-related illness and death;
however, vaccines may be unavailable, in short supply, or ineffective
for certain portions of the population during the first wave of a
pandemic.[Footnote 10] Because a pandemic strain has not emerged and an
effective vaccine needs to be a close match to the actual pandemic
virus, vaccine production for the pandemic strain cannot begin until a
pandemic virus emerges.[Footnote 11] Vaccine production generally takes
at least 6 to 8 months after a virus strain has been identified. The
length of time required to produce the vaccine, combined with limited
U.S. manufacturing capability, could lead to a shortage of vaccines for
the first wave of an influenza pandemic. We previously reported that
limited studies have shown that when a vaccine produces a good antibody
response to a virus, approximately 70 to 90 percent of healthy young
adults may be protected from influenza. This protection drops to about
30 to 40 percent for the elderly and those suffering from chronic
illness or disease.[Footnote 12]
While vaccination has been the primary strategy for preventing
influenza, antiviral drugs can also contribute to the prevention and
treatment of influenza. The Food and Drug Administration has approved
four antiviral medications for the prevention and treatment of
influenza. If taken within 2 days of symptoms, these drugs can reduce
symptoms and make someone with influenza less contagious to others.
According to the Centers for Disease Control and Prevention, these
antivirals are about 70 to 90 percent effective for preventing illness
in healthy adults. However, influenza virus strains can become
resistant, so these drugs may not always be effective. While antiviral
drugs may help prevent or mitigate influenza-related illness or death
until an effective vaccine becomes available, these drugs are expected
to be in short supply during an influenza pandemic.
We previously reported that DOD provides health care to over 9 million
active duty personnel, retirees, and their dependents through the
department's TRICARE program.[Footnote 13] DOD's military health system
has a dual role of medically supporting wartime deployments while
caring for active duty members, retirees, and their families in
peacetime. TRICARE beneficiaries can obtain health care through DOD's
direct care system of military hospitals and clinics, commonly referred
to as military treatment facilities, and through DOD's purchased care
system of civilian providers. The Army, the Navy, and the Air Force
provide most of the system's care through their own medical centers,
hospitals, and clinics, while regional networks of civilian providers
supply the remaining care.
DOD Had Taken Actions to Prepare for an Influenza Pandemic:
DOD began its pandemic influenza planning and preparedness efforts as
early as September 2004, well before the White House issued the
National Strategy for Pandemic Influenza in November 2005 and its
implementation plan in May 2006, and has taken a number of important
actions since then to ensure that the department is ready in the event
of an influenza pandemic. To date, DOD's actions to prepare for an
influenza pandemic include establishing working groups, issuing
guidance, developing plans, establishing Web sites, stockpiling
vaccines and antivirals, and initiating projects to assist other
nations' preparedness efforts. Figure 3 summarizes DOD's efforts to
date related to pandemic influenza planning and preparedness.
Figure 3: Timeline of Actions DOD Has Taken to Prepare for an Influenza
Pandemic Compared to Key Homeland Security Council Plans:
[See PDF for image]
Source: GAO analysis.
[End of figure]
Certain DOD Offices Established Pandemic Influenza Working Groups:
The ASD for Homeland Defense and ASD for Health Affairs, as well as the
Chief of Naval Operations and Commandant of the Marine Corps,
established pandemic influenza working groups. The ASD for Homeland
Defense and ASD for Health Affairs established the Pandemic Influenza
Task Force in November 2005, which was led by the ASD for Homeland
Defense and met bimonthly. As the lead entity for pandemic influenza
policy within the department, the Pandemic Influenza Task Force
coordinated and implemented policies and plans that would (1) prepare
for, prevent, and contain the effects of an influenza pandemic in
military forces, (2) ensure DOD protects U.S. interests at home and
abroad, and (3) render appropriate assistance to civilian authorities
in the United States. The members of the Pandemic Influenza Task Force
included the following:
* Office of the ASD for Homeland Defense:
* Office of the ASD for Health Affairs:
* Office of the ASD for Special Operations and Low Intensity Conflict:
* Joint Chiefs of Staff:
* Office of the Under Secretary of Defense for Intelligence:
* Office of the Under Secretary of Defense for Acquisition, Technology
and Logistics:
* Office of the Under Secretary of Defense (Comptroller):
* Office of the Deputy Under Secretary of Defense for Military
Personnel Policy:
* Office of the Deputy Under Secretary of Defense for Civilian
Personnel Policy:
* Office of the Assistant Secretary of Defense for Public Affairs:
The Deputy Secretary of Defense verbally designated the ASD for
Homeland Defense as the lead for DOD's pandemic influenza planning
efforts and DOD identified four functional leads to oversee the 31
tasks assigned to DOD as a lead agency in the national implementation
plan. In addition to its overall lead role, the Office of the ASD for
Homeland Defense was the functional lead for those tasks in the
national implementation plan related to providing defense support to
civil authorities. The Office of the ASD for Health Affairs was the
functional lead for force health protection tasks in the national
implementation plan. The Office of the ASD for Special Operations and
Low Intensity Conflict was the functional lead for tasks in the
national implementation plan related to stability operations and
international support. Finally, the Joint Chiefs of Staff were
overseeing the combatant commands' planning and implementation efforts.
According to officials in the Offices of the ASD for Homeland Defense
and ASD for Health Affairs, DOD intentionally organized its functional
lead offices to mirror the federal government's organization for
pandemic influenza to improve coordination between DOD and other
federal government agencies. For example, in general, the Office of the
ASD for Health Affairs coordinated with HHS on medical issues and the
Office of the ASD for Special Operations and Low Intensity Conflict
coordinated with the Department of State on international issues.
In addition to the Pandemic Influenza Task Force, in June 2006 the ASD
for Homeland Defense convened a senior officer steering group comprised
of senior military and civilian officials. The steering group was to
meet quarterly and submit a report to the Homeland Security Council
detailing DOD's progress on the actions assigned to the department in
the national implementation plan. The Chief of Naval Operations also
developed a working group, called the Navy Pandemic Influenza Council,
in January 2006, which met quarterly to examine issues related to an
influenza pandemic. The Commandant of the Marine Corps originally
established his own working group that merged with the Navy Pandemic
Influenza Council to create one working group for the Department of the
Navy.
Some Offices and Components Issued Guidance on and Developed Plans for
Pandemic Influenza:
In September 2004, the ASD for Health Affairs issued guidance to the
military departments related to preparing for an influenza
pandemic,[Footnote 14] with the most recent guidance issued in January
2006.[Footnote 15] This guidance is in addition to the department's
existing policies on force health protection. The January 2006
guidance, which supersedes the September 2004 guidance, was developed
by preventive medicine experts in the Office of the ASD for Health
Affairs to provide comprehensive policy guidance for writing the
combatant command and installation pandemic influenza plans. The
guidance also provided information on assumptions to use when
developing plans, such as the percentage of people that could be
affected by a pandemic and that antiviral supplies will likely be
insufficient to meet demands. The guidance listed tasks, such as
developing and exercising plans, for the Office of the Secretary of
Defense, Joint Chiefs of Staff, military departments, installation
commanders, military treatment facility commanders, and Public Health
Emergency Officers to complete for each of WHO's phases of an influenza
pandemic. Additionally, the guidance tasked installations with
developing community containment plans to contain infections at their
source or slow the spread of the disease. The guidance also provided
information on home care infection control that recommended infection
control measures, such as hand washing. Finally, the guidance included
a generic prioritization system for DOD's limited supplies of vaccines
and antivirals and noted that these priorities would be clarified in
the event of an influenza pandemic. Table 1 lists DOD's current generic
priorities for vaccines and antivirals.
Table 1: DOD's Current Priorities for Vaccine and Antiviral
Distribution:
Tier: Tier 1;
Personnel included in tier: Those personnel necessary to respond to
global military contingencies and provide essential health care for the
force structure, including (1) those required to maintain national
strategic and critical operational capabilities, as defined by the
Joint Chiefs of Staff, (2) deployed forces engaged in or supporting
armed conflict, and (3) those personnel necessary to maintain a
functioning health care system.
Tier: Tier 2;
Personnel included in tier: Nondeployed forces that are on alert or
designated to conduct critical contingency operations as defined by the
Joint Chiefs of Staff.
Tier: Tier 3;
Personnel included in tier: Personnel necessary to maintain critical
mission-essential capabilities at each organizational level.
Tier: Tier 4;
Personnel included in tier: All other Active Component or mobilized
reserve component personnel.
Tier: Tier 5;
Personnel included in tier: All other beneficiaries not included
previously according to the Centers for Disease Control and Prevention
priority tiers.
Source: DOD.
Note: DOD's antiviral priorities are the same as its vaccine priorities
except for individuals who are hospitalized due to a pandemic influenza
are in the top tier for antivirals.
[End of table]
The Department of the Navy and the Department of the Air Force planned
to issue servicewide instructions related to pandemic influenza
preparedness. Navy and Marine Corps officials said that the Department
of the Navy was drafting an instruction that would cover all biological
hazards and would include information on an influenza pandemic.
According to a Navy official, the instruction was expected to be
released in the fall of 2006. Similarly, Air Force officials said that
the Department of the Air Force was developing a servicewide
instruction on disease containment that would include guidance on
actions that personnel should take in the event of an influenza
pandemic. The instruction was expected to be released by the end of the
summer of 2006. At the time of our review, the Department of the Army
had not drafted or released a servicewide instruction related to
pandemic influenza for the department; however, its Medical Command and
Installation Management Agency had released guidance to Army military
treatment facilities and installations. In November 2004, the Army
Medical Command tasked its military treatment facilities, including
hospitals and clinics, on Army installations with updating existing
plans for Severe Acute Respiratory Syndrome (SARS).[Footnote 16] The
tasking included guidance to address issues related to influenza
pandemics in the installations' revised plans, such as identifying
facilities other than normal hospital or clinic locations at which mass
vaccinations could be administered. In May 2006, the Army Installation
Management Agency tasked Army installations to develop or update
Installation Emergency Response Plans by the end of June 2006 to
address a response to an influenza pandemic.[Footnote 17] The tasking
included specific guidance on what should be included in the
installation plans, such as incorporating pandemic-specific information
into continuity of operations plans to account for a potential
reduction of staff.
The Office of the ASD for Homeland Defense, with support from the
Offices of the ASD for Health Affairs and ASD for Special Operations
and Low Intensity Conflict and the Joint Chiefs of Staff, completed
DOD's implementation plan for an influenza pandemic, as required by the
national implementation plan. DOD started drafting its implementation
plan in November 2005 and had a draft implementation plan in December
2005. DOD submitted its implementation plan to the Homeland Security
Council in August 2006; however, according to an official in the Office
of the ASD for Homeland Defense, DOD cannot release its implementation
plan externally until after it is coordinated and approved by the
Homeland Security Council. The official said that DOD's implementation
plan provided some guidance on protecting DOD's military and civilian
personnel, contractors, dependents, and beneficiaries in the event of
an influenza pandemic; however, the plan focused on the actions
assigned to DOD in the national implementation plan because force
health protection measures already exist. Appendix II summarizes the
guidance and existing force health protection policies related to DOD's
efforts to protect its workforce in the event of an influenza pandemic.
The officials indicated that DOD expected to update its implementation
plan as needed. DOD's implementation plan also tasked all offices,
components, and agencies departmentwide to begin developing or
modifying existing continuity of operations plans in preparation for an
influenza pandemic.
Additionally, DOD's geographic combatant commands--U.S. Central
Command, U.S. European Command, U.S. Northern Command, U.S. Pacific
Command, and U.S. Southern Command--and installations were tasked with
developing pandemic influenza plans. In November 2005, the Joint Chiefs
of Staff requested that the geographic combatant commands develop plans
for DOD's response to an influenza pandemic that addressed force health
protection, defense support to civil authorities, and support to
humanitarian assistance and disaster relief operations. According to an
official in the Office of the ASD for Homeland Defense, the combatant
command plans would further define how DOD would implement its assigned
actions from the national implementation plan. According to officials
with the Joint Staff, the combatant command plans were almost complete
at the time of our review. Furthermore, the January 2006 Health Affairs
guidance tasked installation commanders with developing pandemic
influenza plans for their installations. According to officials in the
offices of the ASD for Homeland Defense and ASD for Health Affairs, the
military services were responsible for overseeing the installations'
planning efforts.
DOD Established Web Sites for Pandemic and Avian Influenza Information:
The Office of the Deputy ASD for Force Health Protection and Readiness
developed a Web site, the Pandemic Influenza Watchboard, which provided
information to servicemembers and their families on pandemic and avian
influenza.[Footnote 18] The Web site provided answers to frequently
asked questions about avian influenza; links to two of DOD's policies
for pandemic influenza; data on confirmed human and animal H5N1
influenza cases; links to some WHO information on response to and
containment of an influenza pandemic; links to federal government
documents, such as the national implementation plan; and other federal
government Web sites, such as the federal government's pandemic
influenza Web site (www.pandemicflu.gov). Additionally, there was a
link from the Watchboard to DOD's Deployment Health Web site, which is
described below. According to an official from the Office of the ASD
for Homeland Defense, by September 2006, all servicemembers, their
families, and military health system providers will be directed to use
the Watchboard as the primary DOD platform for messages and information
on pandemic influenza, with appropriate hyperlinks to other non-DOD Web
sites.
Additionally, the Deployment Health Support Directorate, within the
Office of the ASD for Health Affairs, established in November 2005 an
informational Web site on avian and pandemic influenza for
servicemembers and their families.[Footnote 19] It included strategies
for personnel to protect themselves, such as avoiding poultry farms in
countries that have had avian influenza outbreaks and washing hands
with soap and water or using alcohol-based hand sanitizer. In addition,
it provided links to additional resources, such as the federal
government's pandemic influenza Web site. At the time of our review,
there was a link from the Deployment Health Web site to the DOD
Military Vaccine Agency's pandemic influenza Web site, but not to DOD's
other pandemic influenza Web sites.
As part of its Disaster Preparedness and Response Information Web site,
DOD's Civilian Personnel Management Service developed a Web site with
some information on pandemic influenza.[Footnote 20] The Web site
provided information for employees, supervisors, and managers, such as
a list of phone numbers that civilian employees could call for
assistance and information; statutory authorities for evacuations; and
general information on pay, leave, telework, and benefits in a natural
disaster or declared emergency. The Web site also provided links to
other resources, such as DOD's Pandemic Influenza Watchboard,
additional information on avian and pandemic influenza on WHO's and the
Centers for Disease Control and Prevention's Web sites, and the Office
of Personnel Management's guidance on human capital planning for an
influenza pandemic.[Footnote 21] The Civilian Personnel Management
Service Web site stated that additional information will be posted as
it becomes available.
Additionally, DOD's Military Vaccination Agency Web site provided
information on pandemic influenza.[Footnote 22] The Web site provided
links to news articles on avian influenza; some of DOD's pandemic
influenza policies and planning documents; two service messages related
to pandemic influenza; questions and answers on avian and pandemic
influenza; and some links to related information, including links to
the Centers for Disease Control and Prevention, WHO, and some DOD
components' Web sites.
DOD Procured Antiviral Medications and Vaccines:
The Office of the ASD for Health Affairs procured antivirals and an
existing H5N1 vaccine. DOD purchased more than 2 million treatment
courses of one antiviral and has prepositioned it at three storage
sites around the world--40 percent of the stockpile is in the
continental United States, 30 percent is in Europe, and 30 percent is
in the Far East.[Footnote 23] According to officials in the Office of
the ASD for Health Affairs, DOD purchased an additional 470,000
treatment courses of the antiviral, which were expected to be delivered
by December 2006, and 241,000 treatment courses of another antiviral,
which were expected to be delivered by March 2007. The additional
treatment courses of the first antiviral would be located at DOD's
military treatment facilities on installations, and the second
antiviral would be distributed among the three antiviral storage sites.
Additionally, DOD purchased an additional 530,000 treatment courses of
the first antiviral, which will increase DOD's stockpile of antivirals
to 3.4 million treatment courses once all of the antivirals are
delivered. The Office of the ASD for Health Affairs purchased more than
2 million doses of an existing H5N1 vaccine based on the strain that
circulated in Vietnam in 2004 and, in fiscal year 2007, planned to
purchase an additional 3.6 million doses of the Vietnam strain and 2.5
million doses of a strain that circulated in Indonesia in 2005.
Officials said that even though a vaccine based on existing strains of
the H5N1 virus will not necessarily protect its recipients from a
further mutated pandemic strain, one option is to vaccinate personnel
with an existing H5N1 vaccine before an influenza pandemic starts,
which may provide personnel some immunity from the disease.[Footnote
24] Officials said that no decision had been made on whether to
vaccinate personnel before a pandemic, but an official in the Office of
the ASD for Health Affairs said that the current plan was not to
administer the vaccine until it had been approved or licensed by the
Food and Drug Administration. According to officials in the Office of
the ASD for Health Affairs, DOD had a verbal agreement with HHS to
purchase additional vaccines for future strains of the virus, including
a pandemic strain.
DOD Initiated Projects to Assist Other Nations' Preparedness:
The ASD for Special Operations and Low Intensity Conflict and the
Defense Security Cooperation Agency issued guidance and accepted
proposals from the combatant commands for projects to build host nation
military capacity for preparing for, mitigating, and responding to a
potential influenza pandemic. The combatant commands could request
funding for projects in four categories: (1) influenza planning and
preparedness assessments, (2) influenza preparedness training programs,
(3) response training and exercise programs, and (4) increasing
military infrastructure capacity. Through the end of July 2006, the
Office of the ASD for Special Operations and Low Intensity Conflict and
the Defense Security Cooperation Agency had approved nearly 50
proposals from the U.S. European Command, U.S. Pacific Command, and
U.S. Southern Command for projects covering 30 countries. Individual
project costs ranged from about $17,000 to $150,000 and totaled over $3
million for fiscal years 2006 and 2007. For example, the U.S. Pacific
Command requested a total of about $72,000 to provide the Chinese and
Indonesian militaries with subject matter experts to share experiences
in operational planning, health surveillance, laboratory testing, and
other preparedness and control activities, including tools and
mechanisms for detecting and tracking cases. Additionally, the U.S.
European Command requested $100,000 to assess the Zambian Defense
Force's current capabilities related to avian influenza and to develop
and implement the capabilities necessary to respond to an avian
influenza outbreak within Zambia.
Going Forward, DOD Faces Four Key Management Challenges in Its Pandemic
Influenza Planning and Preparedness Efforts for Its Workforce
Departmentwide:
DOD began its planning efforts in September 2004 and, to date, efforts
related to protecting DOD's personnel have focused primarily on the
personnel in the military departments, geographic combatant commands,
and installations. However, as the focus shifts to the workforce
departmentwide, including its civilian workforce and personnel at
defense agencies, DOD faces four key management challenges going
forward as the department continues its planning and preparedness
efforts related to an influenza pandemic. First, neither the Secretary
of Defense nor the Deputy Secretary of Defense had yet issued
departmentwide guidance that fully defined an accountability framework
for DOD's pandemic influenza planning efforts, including defining lead
and supporting roles and responsibilities with clear lines of
authority, formal oversight mechanisms, and goals and performance
measures. Establishing an accountability framework could help the
Secretary of Defense or Deputy Secretary of Defense monitor the
department's preparedness for an influenza pandemic. Second, at the
time of our review, DOD had not yet requested funding for its
preparedness efforts that was tied to its departmentwide goals.
Additional funding was necessary to ensure that DOD could complete the
actions assigned to the department in the national implementation plan.
Third, DOD had not yet fully defined and communicated departmentwide
which types of its personnel the department expected to include in its
distribution of vaccines and antivirals in the event of an influenza
pandemic. Clarifying this information before a pandemic may lessen the
confusion over who is to receive DOD-purchased vaccines and antivirals
during an influenza pandemic. Fourth, while certain parts of DOD
received actively distributed guidance and other information, DOD had
not yet fully communicated key information to personnel departmentwide
on actions they should take in the event of an influenza pandemic, as
well as information on the safety and efficacy of vaccines and
antivirals. Ensuring that personnel departmentwide receive information
in advance of an influenza pandemic may lessen confusion about what
actions personnel should take to protect themselves in the event of an
influenza pandemic.
DOD Had Not Yet Fully Defined Departmentwide Lead and Supporting Roles
and Responsibilities, Formal Oversight Mechanisms, and Goals and
Performance Measures for Pandemic Influenza:
At the time of our review, neither the Secretary of Defense nor the
Deputy Secretary of Defense had yet issued guidance that fully and
clearly defined the lead and supporting roles and responsibilities and
clear lines of authority for the organizations involved in
departmentwide pandemic influenza planning efforts, formal oversight
mechanisms, and goals and performance measures for what the leadership
expects from DOD's preparedness efforts. In our prior work, we have
identified six desirable characteristics of strategies.[Footnote 25]
One of these characteristics is that the strategy should address who is
implementing the strategy, what the roles of organizations will be
compared to others, and mechanisms to coordinate efforts. Similarly, in
our work on the federal government's response to Hurricane Katrina, we
found that, in the event of a catastrophic disaster, the leadership
roles, responsibilities, and lines of authority for response at all
levels must be clearly defined and effectively communicated to
facilitate rapid and effective decision making, especially in preparing
for and in the early hours and days after the disaster.[Footnote 26]
Neither the Secretary of Defense nor the Deputy Secretary of Defense
had issued guidance on the specific roles and responsibilities of the
lead and supporting organizations with clear lines of authority for
DOD's pandemic influenza planning efforts. Officials from the Offices
of the ASD for Homeland Defense and ASD for Health Affairs said that
the Deputy Secretary of Defense verbally designated the ASD for
Homeland Defense to lead the department's pandemic influenza planning
and preparedness efforts with the ASD for Health Affairs providing
support on medical force health protection issues. However, at the time
of our review, we were not able to corroborate this information because
a memorandum documenting this verbal agreement had not been distributed
throughout the department. In commenting on a draft of this report, DOD
provided a memorandum dated July 25, 2006, from the Principal Deputy to
the ASD for Homeland Defense that documented this information.
An official from the Office of the ASD for Homeland Defense stated
that, in preparing for an influenza pandemic, organizations would
handle issues for which they are responsible in their existing
directives. However, we observed that the ASD for Homeland Defense had
not issued a directive outlining its office's general roles and
responsibilities. While existing policies and directives outline the
general roles and responsibilities of most DOD organizations, we found
that some organizations within the department were unclear about other
organizations' specific roles and responsibilities related to preparing
for an influenza pandemic. For example, an official from one combatant
command said that clarification was needed on the roles and
responsibilities of the service headquarters compared to the combatant
commands. Moreover, an official in one of the services said that more
guidance was needed on the services' responsibilities in planning for
and responding to an influenza pandemic. Also, a defense agency
official was unsure about the agency's role in preparing for an
influenza pandemic.
In addition to not yet clearly defining the roles and responsibilities
for organizations involved in DOD's pandemic influenza planning
efforts, lines of authority were not yet clearly defined. An official
from the Office of the ASD for Homeland Defense stated that
organizations would maintain their current lines of authority for DOD's
pandemic influenza planning efforts; however, as noted earlier, the ASD
for Homeland Defense currently did not have a directive, which should
outline the office's relationship with others. Additionally, officials
from different DOD organizations told us that the current lines of
authority for DOD's pandemic influenza planning efforts were unclear.
For example, officials from two of the military services said that it
was unusual for the ASD for Health Affairs to task installations
directly with developing plans; rather, the tasking usually comes
through the military services. One official said that installation
personnel in that service were confused about whether or not they were
supposed to be developing plans. We further observed differences in the
military departments' approach to installation planning. Specifically,
the Army Medical Command and Installation Management Agency issued
guidance directing Army installations to plan. On the other hand, an
Air Force official said that the Air Force had not yet tasked its
installations servicewide to develop plans for an influenza pandemic,
but planned to task installations to develop disease containment plans,
which would include information about pandemic influenza, after the Air
Force's related instruction is published. Defining the roles and
responsibilities of the lead and supporting offices and organizations
participating in DOD's pandemic influenza planning efforts
departmentwide with clear lines of authority could better ensure that
there are not gaps in DOD's policies and plans for pandemic influenza
or uncertainty about each organization's authorities and
responsibilities.
While the ASD for Homeland Defense established reporting requirements
for the 31 tasks assigned to DOD in the national implementation plan,
there was no oversight mechanism for those tasks that were not part of
the national implementation plan. DOD's July 25, 2006, memorandum
stated that organizations identified as the lead implementers for the
31 tasks assigned to DOD as a lead agency in the national
implementation plan should report their progress on these tasks each
month. However, this reporting requirement does not apply to other
efforts that DOD has undertaken, including the tasking in DOD's
implementation plan that all DOD organizations develop or revise their
continuity of operations plans in preparation for an influenza
pandemic.
Because of the lack of reporting mechanisms for tasks that are not part
of the national implementation plan, it is unclear whether anyone in
the department had an accurate picture of the status of DOD's
preparedness. At the time of our review, we identified some gaps in
DOD's planning efforts. For example, at that time, only the geographic
combatant commands and installations were required to develop plans for
pandemic influenza. However, numerous DOD personnel would not have been
covered by these plans, such as personnel located in the Pentagon or in
DOD-leased space, functional combatant commands, and defense agencies.
An official in the Office of the ASD for Homeland Defense acknowledged
the gap in planning for personnel in the Pentagon and DOD-leased space.
DOD has since addressed this gap by tasking all DOD organizations to
develop or revise their respective continuity of operations plans in
preparation for an influenza pandemic in DOD's implementation plan.
Additionally, we identified some overlaps in DOD's planning efforts.
For example, the January 2006 Health Affairs guidance tasked the
military departments to develop plans for providing support to civil
authorities and humanitarian assistance, but the combatant commands
were already tasked to address these issues by the Joint Chiefs of
Staff. Without oversight mechanisms that address the full range of
DOD's preparedness efforts, to include those tasks that are not part of
the 31 tasks for which DOD is named as a lead in the national
implementation plan, it is unclear whether anyone in the department has
an accurate picture of the status of DOD's preparedness. As DOD
continues its planning and preparedness efforts for an influenza
pandemic, this lack of a formal oversight mechanism for those tasks
that are not part of the national implementation plan may hamper the
leadership's abilities to ensure that departmentwide planning efforts
are progressing as intended.
Moreover, DOD had not yet established goals or performance measures for
its pandemic influenza preparedness efforts. Another desirable
characteristic of strategies is that they should establish goals for
what the strategy strives to achieve--such as a description of a
desired end-state--and performance measures to gauge progress toward
results. Identifying goals and performance measures aids implementing
parties in achieving results and enables more effective oversight and
accountability. Additionally, the goals would provide a baseline, or
minimum expectation, of what the Secretary of Defense or the Deputy
Secretary of Defense expects from DOD organizations as they move
forward in their planning efforts.
One example of a potential goal, with some modification, for DOD's
pandemic influenza preparedness efforts comes from the department's
January 2006 Health Affairs guidance. The purpose of the January 2006
guidance was to maintain operational effectiveness by minimizing death,
disease, and lost duty time due to an influenza pandemic. While the
purpose of the January 2006 Health Affairs guidance may serve as the
underpinning of a goal for DOD's overall preparedness efforts, we
previously reported that goals should have quantifiable, numerical
targets or other measurable values, which facilitate assessments of
whether overall goals were achieved. Other examples of goals for DOD's
efforts could be ensuring 100 percent of DOD's organizations develop
plans or update existing plans to address pandemic influenza and
communicate this information to personnel, or identifying personnel
supporting critical operations and have a backup plan for their
absence. After DOD has established overall goals for its preparedness
efforts, performance measures can assist DOD in assessing its progress
toward its goals.
Navy officials said that they had started developing plans for pandemic
influenza, but it was difficult because the Office of the Secretary of
Defense had not provided specific information to the military services
on what is expected of the military services in the event of an
influenza pandemic. The Navy officials explained that if the Office of
the Secretary of Defense set goals, such as required readiness levels,
then Navy officials could develop detailed plans for an influenza
pandemic. Without overall goals for DOD's preparedness efforts and
performance measures, it could be difficult for combatant commands, the
military services, and installations to develop plans for an influenza
pandemic and for the Secretary of Defense to gauge the department's
progress toward preparedness as DOD continues its ongoing planning
efforts.
Issuing departmentwide guidance detailing roles and responsibilities,
reporting mechanisms, and goals is not without precedent. For example,
in November 2002, the Secretary of Defense issued a memorandum
initiating DOD's Base Realignment and Closure process. The memorandum
specifically:
* Identified the Deputy Secretary of Defense as the individual
responsible for overseeing the departmentwide process and the Under
Secretary of Defense for Acquisition, Technology and Logistics as the
individual responsible for issuing operating policies and detailed
direction necessary to conduct the process.
* Established two senior groups to oversee the departmentwide efforts
and identified the members of these groups.
* Described the roles of the organizations involved in the effort.
* Established the reporting mechanisms for the process and future
memoranda more clearly defined the specific reporting time frames.
* Established goals for the process.
DOD Had Not Yet Identified an Appropriate Funding Mechanism or
Requested Funding Tied to Departmentwide Goals:
At the time of our review, DOD had started identifying funding
requirements, but had not yet identified an appropriate funding
mechanism or requested funding, tied to its departmentwide goals, for
its pandemic influenza planning efforts. Another desirable
characteristic of a strategy is that the strategy should address
resources, investments, and risk management--what the strategy will
cost; where resources will be targeted to achieve the end-state; and
how the strategy balances benefits, risks, and costs. Using a risk
management approach helps implementing parties allocate resources
according to priorities; track costs and performance; and shift
resources, as appropriate. This information also would assist DOD in
developing a more effective strategy to achieve its desired end-state.
DOD started collecting information on funding requirements for its
pandemic influenza preparedness efforts. In June 2006, the Joint Chiefs
of Staff requested that the combatant commands and military services
identify funding necessary to meet the requirements in the national
implementation plan and the combatant command plans, which could
include funding for force health protection, training and exercises,
laboratory surveillance, and other activities. According to most
officials we met with in the Office of the Secretary of Defense and the
military services, funding was a challenge regarding the department's
influenza pandemic preparedness efforts. For example, according to an
official in the Office of the ASD for Homeland Defense, the national
implementation plan tasked DOD with increased surveillance activities,
which will require substantial additional funding to complete, but DOD
had not yet included this requirement in a budget request to the
Congress.
While DOD had started identifying its funding requirements, at the time
of our review, DOD had not yet identified a mechanism to request
funding to complete the tasks assigned to DOD in the national
implementation plan and protect its own personnel. An official from the
Office of the ASD for Homeland Defense said the department had options
for requesting the required funding, including incorporating the
request in future budget submissions or submitting a supplemental
request to the Congress. An official from the Office of the ASD for
Health Affairs noted that it was difficult for the department to
accurately identify the department's funding requirements before DOD
completed its implementation plan. Additionally, according to the
official, the department was not aware of the funding requirements in
support of the national implementation plan before the department's
previous budget submissions to the Congress. However, there were more
than 50 tasks in the national implementation plan for which DOD was
either a lead or support agency that were to be completed before the
end of 2006. Because DOD had not yet requested funding, it is unclear
whether DOD can address the tasks assigned to it in the national
implementation plan and pursue its own preparedness efforts for its
workforce departmentwide within current resources.
DOD Had Not Yet Defined the Types of Personnel Included in Its Vaccine
and Antiviral Distribution Plans or Communicated That Information
Departmentwide:
At the time of our review, DOD had not yet clearly defined or
communicated departmentwide which types of DOD personnel--military and
civilian personnel, contractors, dependents, and beneficiaries--the
department planned to include in its distribution of vaccines and
antivirals in the event of an influenza pandemic. We have reported on
the importance of DOD managing its workforce from a total force
perspective, which includes active duty and reserve military personnel,
civilian personnel, and contractor personnel.[Footnote 27] In addition
to providing medical care to active duty and reserve personnel, DOD is
required by law to provide medical care to dependents of military
personnel and certain beneficiaries.[Footnote 28] At the same time,
planning to protect all of DOD's active duty and reserve personnel,
civilian personnel, and contractor personnel--as well as beneficiaries
and dependents--with vaccines and antivirals in the event of an
influenza pandemic would require extensive resources and likely is
unrealistic. It will take 6 to 8 months after the pandemic strain is
identified to produce a vaccine and there are only two manufacturers
producing vaccines domestically and a limited number of antiviral
manufacturers. Moreover, there will be widespread demand for vaccines
and antiviral medications.
DOD's guidance was vague as to the types of personnel to be included in
the department's distribution of vaccines and antivirals. The ASD for
Health Affairs developed generic priorities for distributing vaccines
to its personnel, as detailed in table 1, which would be clarified in
the event of an influenza pandemic. While DOD's vaccine and antiviral
priorities specifically mentioned DOD beneficiaries, the guidance did
not clearly state which types of DOD's employees--military personnel,
civilian personnel, and contractors--would receive vaccines and
antivirals from the DOD stockpile. An official in the Office of the ASD
for Homeland Defense said that the primary purpose of DOD's vaccine and
antiviral stockpiles was to preserve the department's ability to meet
the mission requirements of national defense and domestic support. The
official stated that distinctions regarding types of employees--
military personnel, civilian personnel, and contractors--were not made
because whether an individual would be included in the distribution of
vaccines and antivirals was based on whether the individual was
identified as critical to the execution of an essential mission, which
would be determined by components as they developed their continuity of
operations plans. However, this information was not stated in the
January 2006 Health Affairs guidance or DOD's implementation plan.
Additionally, DOD's January 2006 Health Policy guidance stated that
military treatment facilities would obtain vaccines for civilian
beneficiaries through their usual logistics channels or local or state
health departments. Similarly, the military treatment facilities would
obtain antivirals for civilian beneficiaries through their usual
logistics channels or through the local health department to access the
Strategic National Stockpile. An official in the Office of the ASD for
Homeland Defense stated that specific use of the antiviral supply
through the Strategic National Stockpile would be described in an
updated antiviral release policy that was expected to be issued soon.
The lack of clarity of which types of personnel DOD plans to include in
its distribution of vaccines and antivirals could lead to confusion
among personnel as to whether they will receive vaccines and antivirals
from the department or should try to obtain them from other sources.
A major factor affecting DOD's ability to clarify priorities for the
department's current and future vaccine supplies is that DOD's priority
for receiving future influenza vaccines from HHS had not yet been
defined. The Office of the ASD for Health Affairs had a verbal
agreement with HHS to purchase vaccines for future strains of
influenza, including the pandemic strain. In the event of an influenza
pandemic, there will likely be high, widespread demand for a vaccine
across the United States and vaccine production capabilities will be
limited, particularly compared to the demand. At the time of our
review, DOD's priority compared to others for receiving vaccines for
future strains--including the pandemic strain--and how many vaccines it
will receive was not defined and DOD did not have a written agreement
with HHS addressing these issues. An official from the Office of the
ASD for Health Affairs said that the prioritization of vaccines for
future influenza strains, including the pandemic strain, from the HHS
contract with the vaccine manufacturer was being reevaluated by the
Homeland Security Council; however, the official said that previous
discussions had placed DOD in the first tier of agencies to receive the
vaccine for a pandemic strain when it becomes available. The exact
number of vaccine doses for future influenza strains that will be
available is unknown, in part because of the unknown production output
for a pandemic-specific vaccine. Under these circumstances, the
department cannot realistically determine how well it will be able to
meet its priorities for vaccinating personnel. Additionally, without
knowing a rough estimate of how much vaccine will be available, DOD
cannot accurately determine the funding required to purchase vaccines
or, if needed, additional antivirals.
Although a Communications Strategy Was under Development, DOD's
Communication Efforts to Date Were Inconsistent Departmentwide:
At the time of our review, DOD was developing a communications strategy
for an influenza pandemic, and while not fully developed, it continues
to evolve. We reported that communication on threats should be timely
and include specific information on the nature, location, and timing of
the threat as well as guidance on actions to take in response to the
threat to ensure early and comprehensive information sharing and allow
for informed decision making.[Footnote 29] These risk communication
concepts have been used in a variety of warning contexts, including
warnings of infectious disease outbreaks. Additionally, the national
implementation plan states that government officials must communicate
clearly and continuously with the public now and throughout a pandemic,
and public officials at all levels of government must provide
unambiguous and consistent guidance on what individuals can do to
protect themselves, how to care for family members at home, when and
where to seek medical care, and how to protect others and minimize the
risks of disease transmission. However, so much is unknown about a
potential influenza pandemic that it is difficult to provide extensive
information on preparing for an influenza pandemic.
Some, but not all, organizations received frequent communications about
avian or pandemic influenza. Several officials across the department
said their organizations distributed information about the current
avian influenza threat and pandemic influenza to their personnel. For
example, an official from U.S. Northern Command's Washington office
mentioned receiving frequent e-mails from the command on the status of
avian influenza. In contrast, it was unclear whether other DOD
organizations, such as the defense agencies, received and distributed
such information to their personnel. For example, at least one defense
agency had not received any information on planning or preparing for an
influenza pandemic, including what actions its personnel should take in
the event of an influenza pandemic. DOD officials said the department's
communications with its personnel were currently limited, in part
because DOD's communications strategy for an influenza pandemic still
was under development and had been implemented only to a limited
extent. As a result, there currently may be gaps and unevenness in
awareness among DOD's personnel across the department, including
military and civilian personnel, contractors, dependents, and
beneficiaries, about actions they should take in the event of an
influenza pandemic, which could lead to confusion and increased numbers
of personnel affected by a pandemic.
Officials from the Offices of the ASD for Homeland Defense and ASD for
Health Affairs said that DOD planned to use communications strategies
already in place in addition to those created specifically for an
influenza pandemic to share information on the disease to ensure that
personnel know how to protect themselves. DOD's January 2006 Health
Affairs guidance, which was issued to the military departments but not
departmentwide, provided some information on actions, such as hand
washing, that personnel should take in the event of an influenza
pandemic. According to a public affairs official with the Joint Staff,
the department planned to use its existing influenza Web sites, as well
as key messages that will be distributed at the installation level, to
let personnel know what actions to take in the event of an influenza
pandemic. Existing Web sites had some information on what personnel
should do to protect themselves, but as DOD continues its planning and
preparedness efforts, more information could be added. For example, one
Web site mentioned, among other things, that personnel should wash
hands and cover coughs and sneezes; however, there was no information
on what personnel should do specifically in the event of an influenza
pandemic, such as the department's policies on who should seek medical
care at DOD's military treatment facilities or whether personnel should
telework from home during an influenza pandemic. Using multiple
methods--both active and passive--of sharing information on what
actions to take in the event of an influenza pandemic will be useful.
For example, some of DOD's personnel are deployed in austere or rural
environments and may not have access to the Internet and, therefore,
may not have access to the information currently posted on various Web
sites.
In addition to providing information passively on Web sites and
actively through distributed messages, there is a need to communicate
with employees deemed "critical" and in the top tiers for vaccine and
antiviral distribution. These personnel will need to know who they are
and when and where they should obtain vaccines and antivirals.
Conversely, employees in the lower tiers for vaccine and antiviral
distribution will need to be told that they will need to rely on other
resources to obtain these treatments, such as HHS's Strategic National
Stockpile or other state and local public health sources.
DOD also had not yet developed a plan to communicate information to its
personnel on the efficacy of vaccines and antivirals, in the event DOD
decides to dispense those it has purchased to date, but it had posted
the package inserts for the two antivirals that it purchased on one of
its Web sites. In 2002, we reported that survey respondents from the
Air National Guard and Air Force Reserve were generally dissatisfied
with the information DOD provided about its Anthrax Vaccine
Immunization Program. They were particularly concerned about the (1)
military threat from anthrax, (2) anthrax vaccine's battlefield
effectiveness, (3) vaccine's history and past usage, (4) short-term and
long-term safety risks of the vaccine, and (5) possible side effects
from reactions to the vaccine.[Footnote 30] As indicated earlier, DOD
is considering whether or not to vaccinate personnel before an
influenza pandemic to possibly provide personnel some degree of
immunity from the pandemic strain. Based on DOD's experience with the
anthrax vaccine, if DOD decides to vaccinate its personnel early or
after an influenza pandemic starts, then the department would benefit
from a plan addressing how it will communicate information to its
personnel on the threat of an influenza pandemic and the vaccine's
efficacy, risks, and potential side effects.
Conclusions:
To date, DOD's efforts to protect its personnel from an influenza
pandemic have focused primarily on the military departments, geographic
combatant commands, and installations. However, going forward, as the
department's focus shifts to the workforce departmentwide, DOD faces
some key management challenges as it continues its planning and
preparedness efforts related to an influenza pandemic. While we
recognize that DOD's planning for an influenza pandemic continues to
evolve, we believe DOD's planning efforts would benefit from taking
steps to address the challenges and gaps we have identified. Planning
in an environment of tremendous uncertainty for a large workforce
deployed worldwide is an extremely difficult and complex task. Although
DOD has mechanisms, systems, and processes in place for force health
protection, an influenza pandemic would create a different set of
challenges for DOD. Unlike most diseases, an influenza pandemic would
spread quickly around the world and, according to government estimates,
the disease could result in a 40 percent absenteeism rate in general
through illness, taking care of someone who is ill, or fear of becoming
ill. Although DOD has taken many appropriate and important steps to
prepare for an influenza pandemic, challenges remain. First, DOD's
planning efforts would benefit from an accountability framework, with
clearly defined roles and responsibilities, an oversight mechanism, and
goals and performance measures. Such an accountability framework could
help the Secretary of Defense or Deputy Secretary of Defense to monitor
the department's readiness for an influenza pandemic and the Secretary
of Defense--and the Congress--could better ascertain when and to what
extent the Armed Forces and critical functions departmentwide are
prepared to meet this potential emergency at home and abroad. Second,
by identifying an appropriate funding mechanism and requesting funding
for pandemic influenza preparedness efforts that is tied to the
department's goals, the Secretary of Defense can better ensure that the
department can accomplish its tasks in the national implementation plan
and protect its personnel. Third, going forward, DOD would benefit from
clarifying in advance and communicating with personnel which types of
personnel it plans to include in its distribution of vaccines and
antivirals, which may lessen the confusion over who is to receive DOD-
purchased vaccines and antivirals during an influenza pandemic. Fourth,
by developing a departmentwide strategy that communicates key
information to all of its workforce, DOD's military and civilian
personnel, contractors, dependents, and beneficiaries may better know
what actions to take to protect themselves in the event of an influenza
pandemic.
Recommendations for Executive Action:
To improve accountability and oversight of planning efforts across DOD
as the department continues its pandemic influenza planning for its
workforce, we recommend that the Secretary of Defense do the following.
* Instruct the Assistant Secretary of Defense for Homeland Defense, as
the individual accountable for DOD's pandemic influenza planning and
preparedness efforts, to clearly and fully define and communicate
departmentwide the roles and responsibilities of the organizations that
will be involved in DOD's efforts, with clear lines of authority; the
oversight mechanisms, including reporting requirements, for all aspects
of DOD's pandemic influenza planning efforts, to include those tasks
that are outside of the national implementation plan; and the goals and
performance measures for DOD's planning and preparedness efforts.
* Instruct the Assistant Secretary of Defense for Homeland Defense to
work with the Under Secretary of Defense (Comptroller) to establish a
framework for requesting funding for the department's preparedness
efforts. The framework should include the appropriate funding mechanism
and controls to ensure that needed funding for DOD's pandemic influenza
preparedness efforts is tied to the department's goals.
* Instruct the Assistant Secretary of Defense for Health Affairs to
clarify DOD's guidance to explicitly define whether or how all types of
personnel--including DOD's military and civilian personnel,
contractors, dependents, and beneficiaries--would be included in DOD's
distribution of vaccines and antivirals and communicate this
information departmentwide.
* Instruct the Assistant Secretary of Defense for Public Affairs to
implement a comprehensive and effective communications strategy
departmentwide that is transparent as to what actions each group of
personnel should take and the limitations of the efficacy, risks, and
potential side effects of vaccines and antivirals.
Agency Comments and Our Evaluation:
In written comments on a draft of this report, DOD concurred, with
comment, with four of our five original recommendations, and did not
address one recommendation. DOD also provided technical comments, which
we have incorporated in the report, as appropriate. Based on DOD's
written and technical comments and supporting documentation DOD
provided in response to our draft report, we combined two of our
recommendations and modified another recommendation, as discussed
below.
In written comments, DOD stated that the recommendations in the draft
report reflected information that was over a year old. As stated in our
scope and methodology in appendix I, we based our report on information
gathered from December 2005 through August 2006. Notwithstanding, after
reviewing a draft of this report, DOD provided some additional
documentation, which we incorporated, as discussed below.
We originally recommended that the Secretary of Defense designate a
lead individual within DOD who is accountable to the Secretary for
influenza pandemic planning and preparedness efforts, and provide the
individual with the authority to establish oversight mechanisms,
including reporting requirements, for the department's pandemic
influenza efforts. We also recommended that this lead individual
identify and communicate roles and responsibilities of the offices and
components involved in DOD's preparedness efforts, and the goals and
performance measures for DOD's efforts. In its written and technical
comments, DOD stated that the Deputy Secretary of Defense verbally
designated the ASD for Homeland Defense to lead the department's
preparation for a potential influenza pandemic. Our draft report
reflected this statement and noted we could not corroborate or find
documentation of this verbal designation. DOD's comments referred to a
July 25, 2006, memorandum from the Principal Deputy to the ASD for
Homeland Defense, which we subsequently obtained. This memorandum
states that the Deputy Secretary of Defense designated the ASD for
Homeland Defense to lead the department's preparation for a potential
pandemic influenza. The memorandum also directs individual offices to
carry out each of the 31 tasks for which DOD is the lead agency in the
national implementation plan and report each month on their progress on
the 31 tasks. However, the 31 tasks do not address the entirety of
DOD's planning efforts and specifically exclude DOD organizations'
planning efforts to protect its workforce departmentwide. With regard
to our recommendation to establish goals and performance measures, DOD
concurred and commented that the January 2006 Health Affairs guidance
and the national and DOD implementation plans describe the roles and
responsibilities of several DOD organizations. While we agree that
these documents list specific tasks for some organizations to complete,
they do not address overall roles and responsibilities for
departmentwide pandemic influenza planning efforts. DOD also commented
that the national implementation plan and DOD's implementation plan
already provide specific tasks with specific time frames for
completion. We agree that these implementation plans, as well as the
July 25, 2006, memorandum from the Principal Deputy to the ASD for
Homeland Defense, provide time frames to complete individual tasks.
Nevertheless, the intent of our recommendation is that DOD develop
departmentwide goals and performance measures for DOD's overall
pandemic influenza planning and preparedness efforts, including that
for its total workforce, rather than time frames for individual tasks.
In light of the additional information DOD provided on the role of the
ASD for Homeland Defense as the lead for DOD's pandemic influenza
planning efforts, we revised our recommendation to read that the
Secretary of Defense instruct the ASD for Homeland Defense to clearly
and fully define and communicate departmentwide the roles and
responsibilities of organizations involved in DOD's efforts with clear
lines of authority, oversight mechanisms, and goals and performance
measures for DOD's efforts.
DOD concurred, with comment, with our recommendation that the
Secretary's designated lead for DOD's influenza pandemic planning and
preparedness efforts task the combatant commands and military
departments to identify funding requirements that are linked to the
department's preparedness goals and build them into DOD's future budget
requests. DOD commented, and we acknowledged in our draft report, that
DOD had begun to gather funding requirements for the department's
pandemic influenza efforts. Nevertheless, we modified our
recommendation to include a focus on requesting needed funding that is
tied to departmentwide goals.
DOD's written comments did not address our recommendation that the
Secretary's designated lead for DOD's planning and preparedness efforts
instruct the ASD for Health Affairs to clarify DOD's guidance to more
clearly define the types of personnel included in DOD's distribution of
vaccines and antivirals and communicate this information
departmentwide. However, in its technical comments, DOD stated that the
department's prioritization list for vaccines and antivirals is based
on functional roles in the organization and distinctions in the type of
personnel are not made because these divisions do not reflect function.
DOD also stated that individual components are responsible for
determining which individuals are critical when updating their
continuity of operations plans. We incorporated this information into
our report. We continue to believe our recommendation has merit and
should be implemented because DOD's existing guidance remains unclear
on what types of personnel are included in DOD's distribution of
vaccines and antivirals and components' continuity of operations plans
are not yet complete.
Additionally, DOD concurred, with comment, with our recommendation that
the ASD for Public Affairs clarify and implement a comprehensive and
effective communications strategy. In its written and technical
comments, DOD stated that the Office of the ASD for Public Affairs
developed an annex for DOD's implementation plan and plans to issue an
integrated internal communications plan in September 2006. We are
encouraged that the ASD for Public Affairs is developing an integrated
internal communications plan for reaching DOD's internal audiences.
Because the plan is not yet complete, we continue to believe our
recommendation has merit and should be implemented.
As we agreed with your office, unless you publicly announce the
contents of this report earlier, we plan no further distribution of it
until 30 days from the date of this letter. We will then send copies to
the Chairmen and Ranking Members of the Senate and House Committees on
Appropriations; the Chairmen and Ranking Members, Senate and House
Committees on Armed Services; and other interested congressional
parties. We also are sending copies to the Secretary of Defense;
Secretary of Health and Human Services; Secretary of Homeland Security;
and Director, Office of Management and Budget. We will make copies
available to others upon request. In addition, the report will be
available at no charge on GAO's Web site at [Hyperlink,
http://www.gao.gov].
If you or your staff have any questions concerning this report, please
contact me at (202) 512-5431 or by e-mail at dagostinod@gao.gov.
Contact points for our Offices of Congressional Relations and Public
Affairs may be found on the last page of this report. GAO staff who
made contributions to this report are listed in appendix IV.
Signed by:
Davi M. D'Agostino:
Director:
Defense Capabilities and Management:
[End of section]
Appendix I: Scope and Methodology:
As part of our review of the Department of Defense's (DOD) planning and
preparedness for a pandemic influenza, we determined (1) actions that
DOD has taken to date to prepare for an influenza pandemic and (2)
management challenges that DOD faces going forward as the department
continues its planning efforts. We are reporting on these issues now so
that DOD can consider and address our findings as the department
continues its planning and preparedness efforts. We have not yet
assessed DOD's implementation plan for pandemic influenza, since it was
not yet complete at the time of our review; however, we plan to assess
DOD's implementation plan, the combatant commands' implementation
plans, and selected installation plans in another report that will be
issued at a later date.
To determine the actions that DOD has taken to date to prepare for an
influenza pandemic, we reviewed a draft of DOD's implementation plan
for pandemic influenza dated March 2006.[Footnote 31] Additionally, we
reviewed guidance issued by the Office of the Assistant Secretary of
Defense (ASD) for Health Affairs in September 2004 and January 2006; a
planning order issued by the Joint Chiefs of Staff to the combatant
commands in November 2005; planning guidance issued by the Army Medical
Command to the Army regional medical commands in November 2004; and
planning guidance issued by the Army Installation Management Agency to
Army installations in May 2006. We also reviewed the department's
existing force health protection directives, which were identified in
DOD's January 2006 Health Affairs guidance and DOD's draft
implementation plan and by officials in the Office of the ASD for
Health Affairs. These directives are summarized in appendix II. We
reviewed the Implementation Plan for the National Strategy for Pandemic
Influenza to understand what was required of federal departments--
including DOD--in their pandemic influenza preparedness efforts.
Furthermore, we reviewed HHS's contract with a vaccine manufacturer and
DOD's antiviral contracts with two manufacturers. Additionally, we met
in the Washington, D.C., area with DOD officials from the Office of the
Under Secretary of Defense for Policy, Office of the ASD for Homeland
Defense, Office of the ASD for Health Affairs, Office of the ASD for
Reserve Affairs, Office of the Deputy Under Secretary of Defense for
Logistics and Materiel Readiness, Office of the Deputy ASD for
Stability Operations, Office of Force Transformation (Defense),
National Guard Bureau, Joint Chiefs of Staff, Department of the Army,
Department of the Navy, Marine Corps Headquarters, and Department of
the Air Force.
To better understand the threat of an influenza pandemic, we met with
officials from the Defense Intelligence Agency's Armed Forces Medical
Intelligence Center, Fort Detrick, Maryland, and the Central
Intelligence Agency, McLean, Virginia.
To determine management challenges that DOD faces as it continues its
planning efforts, we compared the department's actions to date to best
practices that we have identified in our prior work. Specifically, we
compared DOD's actions to date to the desirable characteristics of
national strategies, which state that a national strategy should
include:
* purpose, scope, and methodology;
* problem definition and risk assessment;
* goals, subordinate objectives, activities, and performance measures;
* resources, investments, and risk management;
* organizational roles, responsibilities, and coordination; and:
* integration and implementation.
While we are not yet assessing DOD's draft implementation plan and it
is not a national strategy, we determined that some of the
characteristics are applicable to planning efforts in general,
specifically those related to identifying goals and performance
measures, resources and investments, and organizational roles and
responsibilities. Because we are not yet assessing DOD's implementation
plan, we used the characteristics as guidance for how DOD could
approach its planning efforts, as opposed to a checklist of what DOD
should be doing. Additionally, we relied on our previous work on total
force management to determine which types of personnel DOD should
include in its plans for vaccine and antiviral distribution.
Furthermore, we relied on our previous work on risk communication
principles to determine whether DOD's current communications strategy
meets these principles. Finally, we reviewed our prior work on
influenza pandemics.
We conducted our review from December 2005 through August 2006 in
accordance with generally accepted government auditing standards.
[End of section]
Appendix II: Summary of DOD's Guidance for Pandemic Influenza and
Related Force Health Protection Policies:
Table 2:
Title of guidance, responsible office or organization, and date:
Department of Defense Influenza Pandemic Preparation and Response
Health Policy Guidance (January 2006);
Purpose of guidance: To provide policy and instructions to prepare for
and respond to an influenza pandemic; facilitate integration into the
National Strategy for Pandemic Influenza, outline an appropriate
response for military installations and contingency operations
worldwide, and provide guidance for defense support to civil
authorities;
Applicability of the guidance: Military departments, the Joint Staff,
and the combatant commands; the guidance was provided to the Coast
Guard as a reference.
Title of guidance, responsible office or organization, and date: Policy
for Release of Tamiflu® (Oseltamivir) Antiviral Stockpile During an
Influenza Pandemic (January 2006);
Purpose of guidance: To provide guidance for the release of the
Department of Defense's (DOD) Tamiflu stockpile; establishes generic
prioritization tiers for Tamiflu;
Applicability of the guidance: Applicability was not listed, but
guidance was addressed to the secretaries of the military departments,
Chairman of the Joint Chiefs of Staff, Under Secretaries of Defense,
Commandant of the U.S. Coast Guard, Assistant Secretaries of Defense,
DOD General Counsel, DOD Inspector General, and directors of defense
agencies.
Title of guidance, responsible office or organization, and date: Policy
for the Use of Influenza Vaccine for the 2005-2006 Influenza Season
(November 2005);
Purpose of guidance: To set policy and priorities for use of influenza
vaccine for the 2005-2006 influenza season;
Applicability of the guidance: Applicability was not listed, but
guidance was addressed to the Assistant Secretaries of the Military
Departments for Manpower and Reserve Affairs; Director, Joint Staff;
ASD for Reserve Affairs; Military Department Surgeons General; and
Defense Supply Center Philadelphia.
Title of guidance, responsible office or organization, and date: DOD
Directive 6490.2, Comprehensive Health Surveillance (October 2004);
Purpose of guidance: To establish policy and assign responsibility for
routine, comprehensive health surveillance of all military
servicemembers during active federal service;
Applicability of the guidance: Office of the Secretary of Defense,
military departments, Chairman of the Joint Chiefs of Staff, combatant
commands, defense agencies, DOD field activities, and all other
organizational entities in DOD.
Title of guidance, responsible office or organization, and date: DOD
Directive 6200.4, Force Health Protection (October 2004);
Purpose of guidance: To establish policy and assign responsibility for
implementing force health protection measures on behalf of all military
servicemembers during active and reserve military service;
Applicability of the guidance: Office of the Secretary of Defense,
military departments, Chairman of the Joint Chiefs of Staff, combatant
commands, Office of the Inspector General, defense agencies, DOD field
activities, and all other organizational entities in DOD.
Title of guidance, responsible office or organization, and date:
Department of Defense Guidance for Preparation and Response to an
Influenza Pandemic Caused by the Bird Flu (Avian Influenza) (September
2004);
Purpose of guidance: To provide instruction on actions to take in
preparation for the possibility of an influenza pandemic, to implement
recommendations from the Department of Health and Human Services'
National Pandemic Influenza Response Plan;
Applicability of the guidance: Military departments, nonmilitary
persons under military jurisdiction, selected federal employees, and
family members and other people eligible for care within the military
health system.
Title of guidance, responsible office or organization, and date: DOD
Directive 6200.3, Emergency Health Powers on Military Installations
(May 2003);
Purpose of guidance: To establish policy to protect installations,
facilities, and personnel in the event of a public health emergency due
to biological warfare, terrorism, other public health emergency, or a
communicable disease epidemic;
Applicability of the guidance: Office of the Secretary of Defense,
military departments, Chairman of the Joint Chiefs of Staff, Office of
the Inspector General, combatant commands, defense agencies, DOD field
activities, and all other organizational entities in DOD.
Title of guidance, responsible office or organization, and date: Policy
for Use of Force Health Protection Prescription Products (April 2003);
Purpose of guidance: To establish policy to comply with the statutory
requirement regarding use of prescription-only drugs, vaccines, and
other medical products;
Applicability of the guidance: Applicability was not listed, but
guidance was addressed to the Assistant Secretaries of the Military
Services for Manpower and Reserve Affairs; Director, Joint Staff;
Surgeons General of the Military Departments; and Deputy Director for
Medical Readiness, Joint Staff.
Title of guidance, responsible office or organization, and date: DOD
Directive 6200.2, Use of Investigational New Drugs for Force Health
Protection (August 2000);
Purpose of guidance: To establish policy and assign responsibility
regarding legal requirements for use of investigational new drugs and
designates the Secretary of the Army as the Executive Agent for the use
of investigational new drugs for force health protection;
Applicability of the guidance: Office of the Secretary of Defense,
military departments, Chairman of the Joint Chiefs of Staff, combatant
commands, Office of the DOD Inspector General, defense agencies, DOD
field activities, and all other organizational entities within DOD.
Title of guidance, responsible office or organization, and date: Policy
for DOD Global, Laboratory-Based Influenza Surveillance (February
1999);
Purpose of guidance: To set DOD policy to conduct global, operationally
relevant laboratory-based influenza surveillance;
Applicability of the guidance: Applicability was not listed, but
guidance was addressed to the Surgeons General of the Military
Services; and Deputy Director for Medical Readiness, J-4, Joint Staff.
Title of guidance, responsible office or organization, and date: Joint
Tactics, Techniques, and Procedures for Noncombatant Evacuation
Operations Joint Report 3-07.51 (September 1997);
Purpose of guidance: To guide combatant commanders and their
subordinate joint force and component commanders in preparing for and
conducting noncombatant evacuation operations;
Applicability of the guidance: Commanders of combatant commands,
subunified commands, joint task forces, and subordinate components of
the commands.
Title of guidance, responsible office or organization, and date: DOD
Instruction 3020.37, Continuation of Essential DOD Contractor Services
During Crises (November 1990), Administrative Reissuance Incorporating
Change 1 (January 1996), Enclosure E3, Guidelines for Theater Admission
Procedures;
Purpose of guidance: Enclosure E3 sets policy for civilian contractors
entering a theater of operations, including ensuring them the same
medical care given to military personnel;
Applicability of the guidance: Office of the Secretary of Defense;
military departments including the Coast Guard when operating as a
service in the Navy; Chairman of the Joint Chiefs of Staff and the
Joint Staff; combatant commands; Inspector General; and defense
agencies.
Title of guidance, responsible office or organization, and date: DOD
Directive 1404.10, Emergency Essential (E-E) DOD U.S. Citizen Civilian
Employees (April 1992);
Purpose of guidance: Updates policy, responsibilities, and procedures
regarding employees in civilian positions designated emergency
essential;
Applicability of the guidance: Office of the Secretary of Defense;
military departments, including the Coast Guard when operating as a
service in the Navy; Chairman of the Joint Chiefs of Staff and the
Joint Staff; combatant commands; Inspector General; defense agencies;
and DOD field activities.
Title of guidance, responsible office or organization, and date: DOD
Directive 3025.14, Protection and Evacuation of U.S. Citizens and
Designated Aliens in Danger Areas Abroad (November 1990);
Purpose of guidance: Updates policies, responsibilities, and procedures
for protection and evacuation of U.S. citizens and designated aliens in
danger areas abroad, and assigns responsibilities for noncombatant
evacuation operations planning and implementation;
Applicability of the guidance: Office of the Secretary of Defense;
military departments, including the Coast Guard when operating as a
service in the Navy; Chairman of the Joint Chiefs of Staff and the
Joint Staff; combatant commands; and defense agencies.
Title of guidance, responsible office or organization, and date: DOD
Directive 6205.2, Immunization Requirements (October 1986);
Purpose of guidance: Addresses immunization policies for all armed
forces members, DOD civilian employees, and eligible beneficiaries of
the military health care system;
Applicability of the guidance: Office of the Secretary of Defense;
military departments, including their guard and reserve components;
Organization of the Joint Chiefs of Staff; and defense agencies.
Source: GAO analysis.
[End of table]
[End of section]
Appendix III: Comments from the Department of Defense:
Assistant Secretary Of Defense:
2600 Defense Pentagon:
Washington, DC 20301-2600:
Homeland Defense:
Ms. Davi M. D'Agostino:
Director, Defense Capabilities and Management:
U.S. Government Accountability Office:
441 G Street, N.W.
Washington, DC 20548:
Aug 31 2006:
Dear Ms. D'Agostino:
The Department of Defense (DoD) concurs with comment to all four
recommendations in the report. Our concurrence is contingent on the
following adjustments to the GAO report:
* The report needs to reflect the most current actions by DoD. The
recommendations in the report reflect information that is now over a
year old. The Department has or is currently taking actions addressed
in the report's recommendations.
* The report contains technical errors that must be corrected to
reflect a more accurate picture of the Department's efforts.
Our responses to the recommendations and technical comments are
attached. My point of contact for this action is Colonel Richard M.
Chavez, (703) 697-5415.
Sincerely,
Signed by:
Peter F. Verga:
Principal Deputy:
Attachments:
1. DoD Response to the Recommendations
2. DoD Technical Response:
GAO Draft Report - Dated August 17, 2006 GAO Code 350890/GAO-06-1042:
"Influenza Pandemic: DoD Has Taken Important Actions to Prepare, but
Accountability, Funding, and Communications Need to be Clearer and
Focused Departmentwide"
Department Of Defense Comments To The Recommendations:
Recommendation 1: The GAO recommended that the Secretary of Defense
designate a lead individual within DOD who is accountable to the
Secretary of Defense for influenza pandemic planning and preparedness
efforts, and provide the individual with the authority to establish
oversight mechanisms, including reporting requirements, for the
department's pandemic influenza efforts.
DOD Response: DoD concurs with comment. The Deputy Secretary of Defense
designated the Assistant Secretary of Defense for Homeland Defense,
working in coordination with the Assistant Secretary of Defense for
Health Affairs, to lead the Department's preparation for a potential
pandemic influenza. To integrate and optimize all Department
preparedness and response efforts, a Pandemic Influenza Task Force was
created, chaired by Mr. Paul McHale, the Assistant Secretary of Defense
for Homeland Defense. Dr. William Winkenwerder, Assistant Secretary of
Defense for Health Affairs, has responsibility for avian influenza
force health protection programs and actions, and supports the task
force to ensure optimal public health support to civilian health
authorities. This response is derived from the following documents:
Department of Defense Implementation of the National Plan for Pandemic
Influenza, signed by Mr. Pete Verga, July 25, 2006 and the Avian
Influenza Pandemic Task Force memo, (no date) signed jointly by Mr.
McHale and Dr. Winkenwerder to all Departmental entities.
Recommendation 2: The GAO recommended that the Secretary of Defense
designates a lead to communicate the roles and responsibilities of the
offices and components that will be involved in DOD's preparedness
efforts and the goals and performance measures for DOD's efforts.
DOD Response: DoD concurs with comment. The January 25, 2006,
Department of Defense Influenza Pandemic Preparation and Response
Health Policy Guidance lays out specific roles and responsibilities of
the Office of the Secretary of Defense, the Joint Staff, the Military
Departments, Installation Commanders, and Military Treatment Facility
Commanders. In addition, the National and the DoD Implementation Plans
list specific tasks designed to make the U.S. government prepared in
the face of a pandemic. These tasks come with very specific timelines
for completion and individuals have been assigned as leads for each
task. Some of these tasks require DOD to work with the other
Departments and Agencies to further define specific roles and
responsibilities - many of which will not be realized until all
Department and COCOM plans are completed. Additionally, the Departments
plan is specific to addressing the concerns of the National
Implementation Plan. The measures of performance are clearly outlined
within each task and the goals are to complete the actions within the
identified timeline. In support of this effort, DoD is required to
submit a bi-monthly status report on these tasks to the White House.
The SES General Officer/Flag Officer Steering Committee is the
oversight committee within DoD to track and monitor that status of
these tasks and approve the submission of the bi-monthly report to the
White House.
Recommendation 3: The GAO recommended that the Secretary of Defense
designates a lead to task the Combatant Commands and Military
Departments to identify funding requirements that are linked to the
Department's preparedness goals and build them into DOD's future budget
requests.
DOD Response: DoD concurs with comment. Prior to assessing potential
Pandemic Influenza preparedness costs, several baseline plans had to be
completed in at least draft final status; The National Pandemic
Influenza Implementation plan, The DoD Implementation Plan and the
Geographic Combatant Command plans. The plans provided the draft
framework by which we could then judge our funding requirements. All
the above referenced plans are now complete or in draft. DoD has
conducted a data call to all Services and Combatant Commands for PI
Preparedness costs for FY07 and FY08. We have captured those projected
costs and are now working the appropriate funding vehicle. Options
include, but are not limited to, inclusion in the 08-13 Program
Objective Memorandum, or pursuing supplemental funding.
Recommendation 4: The GAO recommended that the Secretary of Defense
designates a lead to instruct the Assistant Secretaries of Defense for
Public and Health Affairs to clarify and implement a comprehensive and
effective communications strategy Departmentwide that is transparent as
to what actions each group of personnel should take and limitations of
the efficacy, risks, and potential side effects of vaccines and
antivirals.
DOD Response: DoD concurs with comment. OASD(PA) has developed an
annex, which was submitted earlier this year, for the Department's
implementation plan and public affairs guidance that will be issued in
September.
In addition, an integrated internal communications plan for pandemic
influenza is being developed by OASD(PA)'s internal communications
division. This plan identifies opportunities to reach and inform DoD's
internal audiences, including military and civilian personnel,
dependents and retirees about PI and the government's PI response plan,
how to protect against avian flu, and the role of DoD and service
members facing a pandemic threat in the U.S. and internationally.
The plan will utilize broadcast, web, print and outreach tools to
educate and prepare personnel. Internal communications resources
include: Pentagon Channel (Public Service Announcements), Defense Link,
American Forces Press Service, American Forces Radio Television
Services, Stars and Stripes, and American Forces Network.
[End of section]
Appendix IV: GAO Contact and Staff Acknowledgments:
GAO Contact:
Davi M. D'Agostino, Director, 202-512-5431, dagostinod@gao.gov:
Staff Acknowledgments:
Mark A. Pross, Assistant Director; Susan Ditto; Nicole Gore; Simon
Hirschfeld; Aaron Johnson; John E. Miller; and Hilary Murrish made key
contributions to this report.
[End of section]
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FOOTNOTES
[1] Homeland Security Council, National Strategy for Pandemic Influenza
(Washington, D.C.: Nov. 2005).
[2] Homeland Security Council, Implementation Plan for the National
Strategy for Pandemic Influenza (Washington, D.C.: May 2006).
[3] According to DOD officials, DOD would be responsible for National
Guard personnel who have been mobilized under Title 10, United States
Code. Otherwise, the individual states would be responsible for
National Guard personnel serving under Title 32, United States Code, or
under State Active Duty.
[4] DOD released its implementation plan to the Homeland Security
Council on August 16, 2006, as we were completing our review. However,
according to an official in the Office of the ASD for Homeland Defense,
DOD cannot release its implementation plan externally until it is
coordinated and approved by the Homeland Security Council. We reviewed
the final plan and determined that it was not significantly different
from the March 2006 draft that we previously reviewed.
[5] DOD has purchased an additional 470,000 treatment courses of the
antiviral, which are scheduled for delivery by the end of 2006.
Additionally, DOD has ordered another 530,000 treatment courses of the
antiviral, which will increase its stockpile to 3.4 million courses.
DOD has not yet received these two orders.
[6] These vaccines, which have not been approved by the Food and Drug
Administration, may not be effective against a future pandemic strain,
because the pandemic strain has not yet emerged.
[7] GAO, Combating Terrorism: Evaluation of Selected Characteristics in
National Strategies Related to Terrorism, GAO-04-408T (Washington,
D.C.: Feb. 3, 2004).
[8] Although information about the safety and efficacy of treatments
that DOD has purchased to date is available for dissemination, it is
not known whether these treatments would be effective against a future
strain of the virus because an influenza pandemic involving the H5N1
virus has not occurred.
[9] The pandemics of 1957 ("Asian flu") and 1968 ("Hong Kong flu")
caused dramatically fewer fatalities--70,000 and 34,000, respectively,
in the United States--partly because of antibiotic treatment of
secondary infections and more aggressive supportive care.
[10] GAO, Influenza Pandemic: Plan Needed for Federal and State
Response, GAO-01-4 (Washington, D.C.: Oct. 27, 2000).
[11] Although a vaccine for a pandemic strain cannot be developed until
the pandemic strain emerges, some vaccine manufacturers have developed
vaccines based on the H5N1 strain isolated in Vietnam in 2004.
[12] GAO-01-4.
[13] GAO, Defense Health Care: Implementation Issues for New TRICARE
Contracts and Regional Structure, GAO-05-773 (Washington, D.C.: July
27, 2005).
[14] Department of Defense, Office of the Assistant Secretary of
Defense for Health Affairs, Department of Defense Guidance for
Preparation and Response to an Influenza Pandemic Caused By the Bird
Flu (Avian Influenza) (Washington, D.C.: Sept. 21, 2004).
[15] Department of Defense, Office of the Assistant Secretary of
Defense for Health Affairs, Department of Defense Influenza Pandemic
Preparation and Response Health Policy Guidance (Washington, D.C.: Jan.
25, 2006).
[16] United States Army Medical Command, Avian Influenza Planning
Guidance and Tasking (Fort Sam Houston, Tx.: 2004).
[17] United States Army Installation Management Agency, Influenza
Pandemic Preparation and Response (Arlington, Va.: 2006).
[18] See https://fhp.osd.mil/aiWatchboard/index.html.
[19] See http://deploymentlink.osd.mil/medical/medical_issues/immun/
avian_flu.shtml.
[20] See http://www.cpms.osd.mil/disasters/pan.htm.
[21] Office of Personnel Management, Agency Guidance - Human Capital
Management Policy for a Pandemic Influenza (Washington, D.C.: Aug.
2006).
[22] See http://www.vaccines.mil/.
[23] A treatment course consists of two capsules per day for 5 days if
used for treatment, and one capsule per day for at least 10 days for
prevention.
[24] There is currently some scientific debate regarding the
appropriateness of using a pre-pandemic vaccine. In addition to
concerns about the vaccine's effectiveness against a pandemic strain,
some health experts have expressed concern that vaccinating individuals
with a pre-pandemic vaccine could reduce the effectiveness of vaccines
subsequently produced from the pandemic strain for these individuals.
[25] GAO-04-408T.
[26] GAO, Hurricane Katrina: GAO's Preliminary Observations Regarding
Preparedness, Response, and Recovery, GAO-06-442T (Washington, D.C.:
Mar. 8, 2006).
[27] GAO, DOD Personnel: DOD Actions Needed to Strengthen Civilian
Human Capital Strategic Planning and Integration with Military
Personnel and Sourcing Decisions, GAO-03-475 (Washington, D.C: Mar. 28,
2003).
[28] 10 U.S.C. 1071 et. seq.
[29] GAO, Homeland Security: Communication Protocols and Risk
Communication Principles Can Assist in Refining the Advisory System,
GAO-04-682 (Washington, D.C.: June 25, 2004).
[30] GAO, Anthrax Vaccine: GAO's Survey of Guard and Reserve Pilots and
Aircrew, GAO-02-445 (Washington, D.C.: Sept. 20, 2002).
[31] DOD released its implementation plan to the Homeland Security
Council on August 16, 2006, as we were completing our review. However,
according to an official in the Office of the ASD for Homeland Defense,
DOD cannot release its implementation plan externally until it is
coordinated and approved by the Homeland Security Council. We reviewed
the final plan and determined that it was not significantly different
from the March 2006 draft that we previously reviewed.
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